Helmsley: How Housing is Linked to Healthcare Access

Hidden in Plain Sight: How Housing is Linked to Healthcare Access among New Yorkers Since the Pandemic

Francesca Michielli, Mustafa Hussein, Lily Bushman-Copp, Christopher Wimer

July 2026

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 1

INTRODUCTION

At the onset of the COVID-19 pandemic, Columbia University, with support from Robin Hood and The Leona M. and Harry B. Helmsley Charitable Trust, began collecting data on healthcare access and utilization across New York City via the Poverty Tracker (see text box). The objective was to better understand the healthcare needs of New Yorkers and the difficulties they faced in meeting them. As the pandemic strained healthcare systems nationwide, Poverty Tracker data offered a unique opportunity to understand changes in healthcare access and utilization in New York City. As the pandemic has waned in intensity over time, questions about its lingering effects on access to health- care continue to be raised, especially among vulnerable populations. Since 2020, the Poverty Tracker has collected data on healthcare use and access that allow us to explore how disparities in healthcare outcomes have evolved over the course of the pandemic. In this brief, we examine the experiences of New Yorkers with high healthcare needs (“high-need” hence- forth) between 2021 and 2024. Building on earlier reports, we focus on healthcare experiences through the lens of housing hardship , a key but often overlooked driver of health disparities in New York City. 1,2 We analyze how housing hardship has shaped how high-need New Yorkers have sought healthcare, how their care settings have changed as the pandemic has waned, and how their living conditions have shaped their ability to manage their healthcare needs. Together, these findings illuminate the enduring links between housing stability, healthcare access, and health outcomes in New York City.

1 Bentley, R., Mason, K., Jacobs, D., Blakely, T., Howden-Chapman, P., Li, A., Adamkiewicz, G., & Reeves, A. “Housing as a social determinant of health: A contemporary framework." 2 Meltzer, R., & Schwartz, A. “Housing Affordability and Health: Evidence From New York City.”

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 2

KEY FINDINGS g Across both the peak (2021-2022) and waning (2023-2024) periods of the pandemic, high- need New Yorkers experienced higher levels of housing hardship than non-high-need individuals. While experiences of hardship declined overall as the pandemic waned, high-need New Yorkers continued to be twice as likely to face persistent housing hardship relative to their non-high-need counterparts (14% vs. 7% across both periods). High-need New Yorkers also experienced disproportionately poorer housing quality. In our study period: g Among high-need New Yorkers, those with housing hardship continued to face higher barriers to accessing healthcare. Those with housing hardship delayed or went without physical and mental healthcare and found it difficult to attend healthcare appointments at higher rates than those with stable housing. Even as the pandemic waned, these barriers persisted. g As the pandemic waned, high-need New Yorkers, regardless of housing hardship, relied less on doctor’s offices and health centers and were generally less likely to have a usual place for receiving healthcare. At the same time, those experiencing housing hardship were increasingly more likely than their counterparts with stable housing to visit the Emergency Room in the last 6 months. This signals a growing shift towards more reactive care settings than those that offer primary, preventive, continuous healthcare. g Compared to their counterparts with stable housing, high-need New Yorkers with housing hardship experienced greater housing-related healthcare barriers, including being more than twice as likely to face unsafe living conditions and to lack a proper place to recover.

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 3

About the Poverty Tracker Launched in 2012, the Poverty Tracker surveys a representative sample of New Yorkers several times throughout the year, providing critical information on the dynamics of poverty and other forms of disadvantage in the city. Unlike other surveys, the Poverty Tracker explores how New Yorkers experi- ence poverty and material hardship over time, rather than in a single day, month, or year. In addition, the Poverty Tracker focuses on more than income poverty; annually, the study collects data on other core measures of disadvantage, such as material hardships and health problems. We use these alternative measures to understand how certain forms of disadvantage, or multiple, overlapping forms of disadvantage, make it harder for New Yorkers to get by. The Poverty Tracker also collects data on other aspects related to New Yorkers’ well-being, from asset and debt accumulation, to so- cial service program utilization, to spending and consumption patterns, in order to form a better understanding of how New Yorkers are faring within the city. Our Approach For this report, we follow changes in the healthcare experiences of New Yorkers with high healthcare need. We define high need as having multiple chronic health conditions, a work-limiting health condition, or seri- ous psychological distress (see text box). 3

High healthcare need (high need)

Multiple chronic health conditions

Two or more of the following self-reported chronic health conditions: asthma, diabetes, hypertension, cancer, heart disease A health problem or disability that prevents one from working or limits the kind or amount of work one can do A value of 13 or greater on the Kessler Psychological Distress Scale (K6), which indicates serious psychological distress

Work-limiting health condition

Serious psychological distress

Our analysis compares the experiences of high-need individuals across two distinct time periods of the COVID-19 pandemic. We define the “peak” period as 2021–2022, when pandemic-related disruptions in healthcare were most pronounced, and the “waning” period as 2023–2024, when those disruptions began to recede. 4 Grouping responses this way allows us to examine how healthcare access and utilization have shifted as New York City moved from crisis response toward recovery. We define housing hardship as having experienced at least one of the following in a given year: (1) moving in with others due to cost, (2) staying in a shelter or another place of temporary housing for more than one night, or (3) being unable to pay the full amount of rent or mortgage.

3 For each individual, high-need classification is based on their health conditions in the first year of each period. 4 We restrict our analysis to individuals who responded to surveys in both years of a given period. For example, if an individual was included in the 2021 survey but not in the 2022 survey, they were dropped from the analysis.

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 4

We further identify the persistence of housing hardship within each period (see text box). To better capture the duration of these experiences, we classify housing hardship within each period as persistent , some , or none . Individuals who faced housing hardship in both years of a period are categorized as experiencing persistent hardship , those who reported a spell of hardship in only one year are categorized as experienc- ing some hardship , and those who did not report hardship in either year are categorized as having stable housing (no hardship). 5 , 6

Housing hardship classification Persistent hardship

Experienced housing hardship in both years of a period

Some hardship

Experienced a spell of housing hardship in only one year of a period

Stable housing

Experienced no housing hardship in either year of a period

Our full sample consists of 1,912 individuals in the peak period and 1,745 in the waning period. Of those, 650 met our criteria for having high healthcare need (“high-need”) in the peak period and 688 in the waning period.

Sample size Table 1

Full Sample

High-Need Individuals

Peak Period

1,912 1,745 3,657

650 688

Waning Period

Total* 1,338 * Because of the longitudinal nature of the data, some individuals can appear in both periods, so the total does not represent the number of unique individuals. Why Housing? Housing is a central component of affordability in New York City. Approximately two million New Yorkers are rent burdened, spending more than 30 percent of their income on housing, and concerns over housing costs have become central to city and state policy debates. 7,8 Within this broader landscape, housing hardship rep- resents an important economic barrier that can shape how New Yorkers access and experience healthcare. We focus on housing hardship as a barrier to healthcare because stable housing supports essential aspects of care. A safe and consistent place to live is critical for recovering from medical procedures, managing ill- ness at home, storing medications, and maintaining communication with healthcare providers. Conversely, unsafe or unstable housing—whether due to mold, pests, or recurring inability to afford housing—can lead to health complications that themselves require care, adding strain to individuals already facing elevated health needs. 9 5 For instance, if an individual faced housing hardship in 2021 but not in 2022, they are classified as experiencing some hardship in the peak period. 6 For this analysis, we statistically control for the following demographic indicators: race, gender, age, education level, immigration status, months worked per year, poverty gap, housing tenure, number of children in household, number of seniors in household, and number of working-age adults in household. 7 Koutavas, A., Collyer, S., and Jia, Y. "Spotlight: Housing affordability and the threat of cuts to federal housing assistance programs." 8 Brand, D. Affordable housing takes center stage in New York City mayoral race. 9 Bentley, R., Mason, K., Jacobs, D., Blakely, T., Howden-Chapman, P., Li, A., Adamkiewicz, G., & Reeves, A. “Housing as a social determinant of health: A contemporary framework."

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 5

In this brief, we examine how housing hardship intersects with healthcare access among high-need New Yorkers. We assess multiple dimensions of access, including delayed and forgone care, difficulty getting to appointments, and usual places of care. As detailed in prior briefs, access to healthcare has five core dimensions, including affordability and accessibility, and where people receive care is a key indicator of care quality and continuity. 10 We also explore health-related challenges tied directly to living conditions. Findings Changes in housing hardship experience among high-need New Yorkers Across both the peak and waning periods, high-need New Yorkers were more likely to experience housing hardship than those without high healthcare needs (Figure 1). During the peak period, 36% of high-need New Yorkers experienced some or persistent housing hardship, compared to 23% of those without high need. A similar pattern appears in the waning period: 28% of high-need New Yorkers faced hardship, versus 18% of non-high-need New Yorkers. While housing hardship remains elevated among high-need individuals, the share experiencing hardship declined as the pandemic waned for both groups. This decline was driven largely by a reduction in the share of New Yorkers experiencing some housing hardship, that is, a spell of housing hardship in one year. On the other hand, rates of persistent hardship remained stable across periods and groups, with high-need New Yorkers reporting twice the levels of persistent housing hardship than those without high need (14% vs. 7%) across periods. These results extend our prior findings from 2020–2021, showing that high-need New Yorkers continued to face higher rates of housing hardship even as the pandemic waned, underscoring the persistent nature of this challenge. 11

10 The five dimensions are: availability, affordability, accessibility, accommodation, and acceptability. Penchansky and Thomas, “The concept of access: definition and relationship to consumer satisfaction.” Koutavas, A., Hussein, M., Bushman-Copp, L., and Wimer, C. "Patterns of Delayed Healthcare Among New Yorkers with High Healthcare Need Over the Course of the Pandemic." 11 Maury, M. et al. “Health and healthcare in New York City: second report.”

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 6

High-need New Yorkers experience housing hardship at higher rates than non-high-need New Yorkers. Figure 1 Figure 1: High-need New Yorkers experience housing hardship at higher rates than non-high-need New Yorkers.

Persistent Hardship Some Housing Hardship Stable Housing

100%

90%

80%

70%

77%

82%

64%

72%

60%

50%

40%

30%

22%

14%

20%

36%

28%

17%

11%

23%

10%

18%

14%

Peak (2021-2022)

Warning (2023-2024)

Peak (2021-2022)

Warning (2023-2024)

While our measure of housing hardship captures housing instability, it does not fully describe the broader challenges many New Yorkers face in their homes. We also examine housing quality-related challenges by assessing exposure to poor living conditions. The Poverty Tracker asks respondents about six aspects of their physical housing conditions (see text box). 12 Using these data, we construct a Poor Housing Conditions Index that counts the number of adverse conditions a respondent experiences, with scores ranging from zero to six. High-Need Source:Poverty Tracker longitudinal survey data, cohorts three, four, and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Not High-Need Source: Poverty Tracker longitudinal survey data, cohorts three, four, and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition.

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12 Data on housing conditions are only available for the latter part of our study period, and as such we cannot differentiate across periods for this analysis.

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 7

Poor housing conditions

Damaged home

Walls, ceiling, or floors of house or apartment are damaged

Exposure to pests

Has seen mice, rats, bedbugs, or cockroaches in residence

Limited access to heat

Used additional sources of heat during the past winter

Lacks AC

Does not have central air or at least one window AC unit in residence

Visited cooling center

Visited a public cooling center during the past summer

Feels unsafe from crime

Feels “not safe” from crime in public spaces in residence

Poor housing conditions are widespread among both high-need and non-high-need New Yorkers: across both periods, 72% of high-need individuals and 66% of those without high need reported at least one adverse housing condition (Figure 2). Consistent with patterns observed for housing hardship, high-need New Yorkers were more likely to experi- ence multiple poor housing conditions. While one in three non-high-need New Yorkers (33%) reported two or more conditions, this share was even higher among high-need respondents, at 41%—an eight-percent- age-point difference. These findings indicate not only a greater likelihood of exposure to poor conditions among high-need New Yorkers, but also a more concentrated burden of housing quality-related challenges. High-need New Yorkers were more likely to experience poor housing conditions than non-high-need New Yorkers over 2021-2024. Figure 2 Figure 2: High-need New Yorkers were more likely to experience poor housing conditions than non-high-need New Yorkers over 2021-2024.

0 1

2 3 4 5 6

Index Score

20% 30% 40% 50% 60% 70% 80% 90% 100%

28%

34%

31%

33%

72%

66%

21%

18%

41%

33%

7% 11%

10% 0%

3% 10%

Non High-Need

High-Need

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 8 Note: Due to rounding, some figures may not total to 100% Source: Source: Poverty Tracker longitudinal survey data; cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Source: Poverty Tracker longitudinal survey data, cohorts four and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Note: Due to rounding, some figures may not total to 100%.

Focusing on high-need New Yorkers, Figure 3 shows the distribution of zero, one, and two or more poor housing conditions (grouped for ease of interpretation) by housing hardship classification. High-need New Yorkers who experienced housing hardship were more likely to report these poor housing conditions than those with stable housing. Individuals with persistent housing hardship were the most likely to report two or more poor housing conditions (61%), compared with 56% of those with some hardship and 33% of those with stable housing. High-need New Yorkers experiencing housing hardship also faced poorer living conditions over 2021-2024. Figure 3 Figure 3: High-need New Yorkers experiencing housing hardship also faced poorer living coniditons over 2021-2024 (Copy) Index Score 0 1 2 3 4 5

2+ Index Score 1

Stable Housing

33%

32%

35%

Some Housing Hardship

56%

26%

18%

Persistent Housing Hardship

61%

34%

SPECIAL SERIES: HEALTH & HEALTHCARE IN NY 9

Housing hardship is associated with lower access to healthcare We next examine how housing hardship relates to healthcare use among high-need New Yorkers. High- need individuals who experienced housing hardship were more likely to delay or go without physical health- care than those with stable housing (Figure 4). During the peak period, high-need New Yorkers with persistent housing hardship were 30 percentage points more likely to delay or go without physical healthcare than those with stable housing, and 15 percentage points more likely than those experiencing some hardship. This gradient by hardship level continued into the waning period, with those facing persistent hardship continuing to exhibit the highest rates of delayed or forgone care even though they experienced some decline from the peak to the waning period. High-need New Yorkers with housing hardship were more likely to delay or forgo physical healthcare than those with stable housing. Figure 4 Figure 6: As the pandemic waned, a growing share of high-need New Yorkers reported difficulty getting to their last healthcare appointment.

Stable Housing Some Housing Hardship Persistent Housing Hardship

70%

60%

50%

40%

29%

30%

22%

21%

19%

20%

14%

10%

Peak (2021 - 2022)

Waning (2023 - 2024)

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 10

High-need New Yorkers delayed or went without mental healthcare at higher rates than physical health- care. Among those with persistent housing hardship, 60% during the peak period and 63% during the waning period reported delaying or not receiving needed mental health services. As with physical health- care, those with persistent hardship consistently had the highest rates of unmet care: in the peak period, individuals with persistent hardship were nearly twice as likely to go without mental healthcare as those with stable housing (60% vs. 32%). As the pandemic waned, the share of high-need New Yorkers delaying or going without mental healthcare increased among those with stable housing and those with persistent hardship, while it declined somewhat among those with some housing hardship (that is, a spell of housing hardship in one year) . Figure 5: High-need New Yorkers with persistent housing hardship were more likely to delay or forgo mental healthcare than those with stable housing. High-need New Yorkers with persistent housing hardship were more likely to delay or forgo mental healthcare than those with stable housing. Figure 5

Stable Housing Some Housing Hardship Persistent Housing Hardship

100%

90%

80%

70%

63%

60%

54%

47%

50%

45%

40%

32%

30%

20%

10%

Peak (2021 - 2022)

Waning (2023 - 2024)

High-need New Yorkers experiencing housing hardship also reported greater difficulty getting to their health- care appointments (Figure 6). During the peak period, 21% of those with some hardship and 19% of those with persistent hardship reported difficulty getting to their last appointment, roughly double the level among those with stable housing (10%). By the waning period, difficulty getting to appointments increased across all groups. The share of individuals with persistent hardship reporting difficulty rose to 29%, more than double the level among those with stable housing (14%). As in-person utilization of healthcare became more com- monplace as the pandemic waned, so too did New Yorkers’ reported difficulty getting to their appointments. Note: Results are among high-need New Yorkers who reported needing mental healthcare. Source: Poverty Tracker longitudinal survey data, cohorts three, four, and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Source: Poverty Tracker longitudinal survey data, cohorts three, four, and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Note: Results are among high-need New Yorkers who reported needing mental healthcare.

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 11

As the pandemic waned, a growing share of high-need New Yorkers reported difficulty getting to their last healthcare appointment . Figure 6 Yorkers reported difficulty getting to their last healthcare appointment.

Stable Housing Some Housing Hardship Persistent Housing Hardship

100%

90%

80%

70%

60%

50%

40%

29%

30%

22%

21%

19%

20%

14%

10%

Peak (2021 - 2022)

Waning (2023 - 2024)

The results from this section indicate that among high-need New Yorkers, housing is not an isolated chal- lenge; it is closely linked to barriers in accessing healthcare. High-need individuals experiencing housing hardship were consistently more likely to delay or go without needed physical and mental healthcare and more likely to report difficulty getting to their appointments than high-need individuals without hardship. Delaying or forgoing necessary healthcare can worsen symptoms and exacerbate underlying illnesses, po- tentially increasing the future need for care (and its eventual costs). 13 Prior briefs show that affordability and insurance coverage remain key factors limiting access to care among economically disadvantaged New Yorkers, underscoring the role of cost in these unmet needs. 14 Taken together, these findings emphasize the ongoing economic barriers to receiving timely care, par- ticularly for high-need New Yorkers facing compound economic disadvantage and persistent housing instability. Source: Poverty Tracker longitudinal survey data, cohorts three, four, and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Source: Poverty Tracker longitudinal survey data, cohorts three, four, and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition.

13 Weissman et al., “Delayed access to health care: Risk factors, reasons, and consequences.” 14 Koutavas, A., Hussein, M., Bushman-Copp, L., and Wimer, C. "Patterns of Delayed Healthcare Among New Yorkers with High Healthcare Need Over the Course of the Pandemic."

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 12

Housing hardship and where high-need New Yorkers usually seek healthcare As the pandemic waned, high-need New Yorkers reported less reliance on doctor’s offices and health cen- ters as their usual source of care (Figure 7). At the same time, a growing share reported having no usual place to receive healthcare. Between the peak and waning periods, the share who most often visited a doc- tor or health center declined by 9 percentage points for those with stable housing and those with persistent hardship, and by 4 percentage points for those with some hardship. Over the same period, the share report- ing no usual place of care increased from 1–4% in the peak period to 10–13% in the waning period. Figure 7: As the pandemic waned, high-need New orkers relied less on doctor’s offices as their most common place of care, and more reported having no regular source of care. As the pandemic waned, high-need New Yorkers relied less on doctor’s offices as their most common place of care, and more reported having no regular source of care . Figure 7

Stable Housing

Some Housing Hardship Persistent Housing Hardship

Doctor’ office or Health Center

No Usual Place of Care

100%

89%

87%

90%

80%

79%

78%

80%

75%

70%

60%

40% 50%

30%

10% 20%

13%

11%

10%

1% 4% 4%

Peak (2021 - 2022)

Warning (2023 - 2024)

Peak (2021 - 2022)

Warning (2023 - 2024)

Source: Poverty Tracker longitudinal survey data, cohorts three, four, and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. A shift toward more reactive care settings, including emergency rooms (ER) and urgent care centers, helps explain the declining use of physician offices as a usual source of care. Between the peak and wan- ing periods, the share of New Yorkers who reported visiting an emergency room in the past six months increased across all groups (Figure 8). This rise was most pronounced among those facing persistent housing hardship, for whom ER use rose from 27% to 39%. Use of urgent care centers, whose popularity rose during the pandemic, remained consistently high across both periods, ranging from 39% to 47%. 15 Source: Poverty Tracker longitudinal survey data, cohorts three, four, and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition

15 Koutavas, A., Hussein, M., Bushman-Copp, L., and Wimer, C. "Places of Healthcare Receipt Among New Yorkers with High Healthcare Need Over the Course of the Pandemic."

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 13

High-need New Yorkers reported increased emergency room use in the waning period compared to the peak period, while urgent care utilization remained high across both periods. Figure 8 Figure 8: High-need New Yorkers reported increased emergency room use in the waning period compared to the peak period, while urgent care utilization remained high across both periods.

Stable Housing

Some Housing Hardship

Persistent Housing Hardship

Urgent Care

Emergency Room

100%

90%

80%

70%

60%

47%

50%

45%

42%

40%

39%

40%

33%

27% 27%

30%

21%

17%

20%

10%

Peak (2021 - 2022)

Waning (2023 - 2024)

Peak (2021 - 2022)

Waning (2023 - 2024)

As the pandemic waned, a growing share of high-need New Yorkers lacked a regular place of care, suggesting a broader decline in routine, proactive engagement with the healthcare system. In turn, New Yorkers were more likely to rely on reactive settings, such as emergency rooms and urgent care centers, when health- care needs arise. These patterns likely reflect multiple factors, including the expiration of pandemic- era public insurance expansions, difficulty maintaining continuous primary care relationships during and after the pandemic, and general care-seeking fatigue following the peak period. Source: Poverty Tracker longitudinal survey data, cohorts three, four, and five. High-need refers to NewYorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Source: Poverty Tracker longitudinal survey data, cohorts three, four, and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 14

Housing conditions and the ability to manage health needs In the preceding sections, we examined how housing hardship relates to several measures of healthcare access. We now turn to housing-related healthcare barriers: challenges that directly affect a person’s ability to manage their health needs because of their living conditions. In 2023-2024 only (waning period), the Poverty Tracker asked respondents in the full sample whether they have experienced any of the problems listed in the text box below. Accordingly, we restrict this analysis to the waning period. Together, these questions capture multiple ways in which housing conditions can shape healthcare management.

Housing-Related Healthcare Barriers Medication storage

Difficulty storing or refrigerating prescription medications or other medical supplies Not having a regular place or phone where you can be contacted by a doc- tor or medical professional Not having a clean and comfortable place where you can recover and treat health problems Unsafe living conditions such as mold, lead exposure, inadequate heat, or missing railings

Irregular place of contact

Space for recovery

Unsafe conditions

Other

Other healthcare issues related to housing situation

Housing-related healthcare barriers are far more common among those facing housing hardship (Figure 9). Among high-need New Yorkers with stable housing, 9% reported at least one barrier to managing their health. This share was nearly twice as high (16%) among those experiencing some hardship, and nearly three times as high (24%) among those with persistent hardship. Individuals facing housing hardship experienced housing-related healthcare barriers at more than twice the level of those with stable housing over 2023-2024. Figure 9 Figure 9: Individuals facing housing hardship experienced housing-related healthcare barriers at more than twice the level of those with stable housing over 2023-2024.

Stable Housing Some Housing Hardship Persistent Housing Hardship

20% 30% 40% 50% 60% 70% 80% 90% 100%

24%

16%

10% 0%

Stable Housing

Some Housing Hardship Persistent Housing Hardship

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 15 Poverty Tracker longitudinal survey data, cohorts four and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Source: Poverty Tracker longitudinal survey data, cohorts four and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Source:

The most common barriers involve difficulty recovering at home and unsafe living conditions (Figure 10). High-need New Yorkers with housing hardship were more likely to report not having a clean and comfort- able place to recover, with 7% of those facing some hardship and 11% of those with persistent hardship re- porting this challenge, compared to just 3% of those without hardship. A similar pattern appears for unsafe living conditions, such as exposure to mold or lead: 9–11% of those with housing hardship reported unsafe conditions, compared to 4% of those with stable housing. The most common housing-related healthcare barriers were lack of a clean place to recover and unsafe living conditions, such as mold and lead exposure, over 2023-2024. Figure 10 Figure 10: The most common housing-related healthcare barriers were lack of a clean place to recover and unsafe living conditions, such as mold and lead exposure, over 2023-2024.

Stable Housing

Some Housing Hardship

Persistent Housing Hardship

20%

18%

16%

14%

11%

12%

11%

10%

No Clean Place to Recover

Unsafe Living Conditions

Source: Poverty Tracker longitudinal survey data, cohorts four and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Source: Poverty Tracker longitudinal survey data, cohorts four and five. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. The findings in this section confirm that high-need New Yorkers experiencing housing hardship not only face greater barriers to accessing healthcare but are also more likely to live in conditions that directly com- promise and impede their ability to manage their health.

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 16

Housing and healthcare in the lived experience of high-need New Yorkers The data in this brief suggest that high-need New Yorkers with unstable housing face more health-related challenges than those with stable housing. However, the true picture for many New Yorkers is more compli- cated: housing stability does not guarantee quality housing and stable health. Marlene, 61, who we interviewed in September 2021 and again in March 2023, has multiple chronic physical and mental health conditions. After being hospitalized with severe COVID in the spring of 2020, she had a long road to recovery both physically and mentally: “I had to learn to walk again, learn how to use a bathroom again. I had to learn how to pick up stuff, just pick up stuff with my hands... I still got COVID brain.” She lives alone in the Bronx apartment she has held onto for 20 years. Unable to work due to her health, she survives on a small income of disability insurance and food stamps. A Section 8 voucher covers the majority of her rent, and Marlene prioritizes her contribution: “I always try to keep my rent paid. Because I know I have to pay it. I need a place to stay.” Still, during the height of the pandemic she fell behind on rent a couple of times and struggled to keep up with her expenses: “It gets crazy. Bills get paid. I just try to catch up on it when I can.” Unlike the high-need New Yorkers who struggle with persistent housing hardship that we investigate in this report, Marlene has maintained stable housing thanks to her Section 8 rent subsidy. This has been a lifeline that allowed her to recuperate from long Covid and to stay connected to care. However, the quality of Marlene’s building has deteriorated over time, exposing her to many of the housing issues common among high-need New Yorkers who do experience hardship. Marlene no longer feels safe in her apartment building: “The doors always being broken downstairs…I’ve never experienced so many people, strangers getting high in the hallways. People you don’t know is in the hallways, going in and out of the building. It’s dangerous... The whole block is full with just people selling drugs. When I get past this door, it’s you do what you gotta do, and hurry and get back in the house.” Safety concerns are not the only reason Marlene goes outside less frequently now. She uses a walker, and getting up and down from her apartment is challenging: “I don’t go out much because of the steps. I’m on the second floor. I don’t have an elevator in my building. I don’t go out much at all.”

There is also a pest problem in her apartment that affects her health:

“Well, I have plenty of rats. I have gotten a cat. I’m not supposed to have any cat because it’s bad for my health because of my asthma. It triggers it. It’s either the rats or the cat. I keep the cat.”

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 17

At the second interview, her stove, which she relies on to prepare nutritious meals that keep her dia- betes under control, hadn’t been working for over 6 months, and she was taking her landlord to court over lack of repairs. Marlene relies on dual Medicaid-Medicare insurance coverage, but, because her primary provider’s office is in Westchester, not the Bronx, she finds it difficult to access care. She may end up leaving this doctor because it is hard to find reliable transportation to get to her appointments on time. At the first interview, Marlene expressed a need for mental health counselling. One and a half years later she had entered a depression following the death of her father, and still hadn’t found a therapist: “I still, as of today, haven’t had any help, and I’ve been tryin’ to get help almost—it’s been since the beginning of last year… What do I have to do? I think I tried lookin’ up a therapist on—I think it was like a insurance thing, whatever it is, but then they still have no one available at this time, so I did try to do somethin’ a little bit differ- ent, but at that point, I don’t know what else to do.” Marlene’s circumstances illustrate the protective nature of rent subsidy programs in allowing high- need, economically disadvantaged New Yorkers to avoid the housing hardship that pervades this de- mographic and disrupts healthcare access for those who need it most. But when this stable housing is in such a poor condition, its ability to support residents’ health is greatly undermined. In Marlene’s case, her poor housing conditions exacerbated preexisting physical and mental health issues, such as her asthma, diabetes, and depression, and made it difficult for her to seek needed care.

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 18

CONCLUSION

As New York City moved into the post-pandemic period, the healthcare experiences of high-need New Yorkers continued to reflect persistent inequality. Across this brief, we find that housing hardship is closely linked to barriers in accessing care: high-need New Yorkers with housing hardship were more likely to delay or go without physical and mental healthcare and had greater difficulty getting to appointments. They also faced housing conditions, such as unsafe environments or a lack of space to recover, that directly under- mined their ability to manage their health. As the pandemic waned, fewer high-need New Yorkers reported having a usual place of care and more went to emergency rooms, especially those with persistent housing hardship. These trends echo findings from earlier briefs showing that high-need New Yorkers facing economic disadvantage continued to strug- gle with affordability, appointment access, and consistent engagement with primary care as the pandemic waned. Taken together, these results show that for high-need New Yorkers, housing hardship and healthcare access are deeply intertwined. Even as some pandemic-related disruptions receded, those experiencing housing instability continued to face substantial obstacles to maintaining their health, highlighting the need for co- ordinated efforts that address both housing and healthcare access for those with the greatest needs.

HOW HOUSING IS LINKED TO HEALTHCARE ACCESS AMONG NEW YORKERS SINCE THE PANDEMIC 19

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